What Are Medicare Advantage Plans in the District of Columbia?

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans bundle Medicare Part A (hospital) and Part B (medical), and most include prescription drug coverage (Part D). Many plans also offer extra benefits such as dental, vision, hearing, telehealth, fitness memberships, and over-the-counter allowances.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, though those with qualifying disabilities or conditions such as ALS or ESRD may qualify earlier.

Enrollment periods include:

• Initial Enrollment Period
• General Enrollment Period
• Special Enrollment Periods

Late enrollment may result in penalties unless you qualify for premium-free coverage.

What Types of Medicare Advantage Plans Are Available in the District of Columbia?

D.C. offers the following Medicare Advantage (MA) plan types:

• Health Maintenance Organizations (HMOs): Require in-network care and referrals for specialists; lower average premiums.
• Preferred Provider Organizations (PPOs): Permit out-of-network care at higher costs; no referrals required.
• Private Fee-for-Service (PFFS) Plans: Any Medicare-approved provider who accepts the plan’s terms may be used.
• Special Needs Plans (SNPs):
  • C-SNPs: For those with chronic conditions (e.g., diabetes, COPD).
  • I-SNPs: For individuals in institutional or nursing care settings.
  • Dual Eligible Special Needs Plans (D-SNPs): For those with both Medicare and Medicaid, often at low or no cost.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account funded by your insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

Most MA plans include Part D drug coverage. Exceptions include MSAs and some PFFS plans. If your MA plan doesn’t include drug coverage, you may:

• Enroll in a separate Part D plan (if eligible).
• Face a late enrollment penalty if you delay drug coverage and lack creditable coverage.

How Do You Choose a Medicare Advantage Plan?

Use this guide on Medicare Advantage costs to make an informed decision. Key considerations include:

• Premiums: Some D.C. plans have $0 premiums, but you’ll still owe your Medicare Part B premium.
• Deductibles, Coinsurance & Copays: Determine your total out-of-pocket obligations for doctor visits, hospital stays, and prescriptions.
• Out-of-Pocket Maximums: MA plans cap your yearly spending on covered services.
• Extra Benefits: Evaluate non-covered benefits like dental, vision, telehealth, and fitness options.

When and How Do You Enroll in a Medicare Advantage Plan?

You must enroll in Medicare before joining an MA plan. Enrollment windows include the following specific enrollment periods:

• Initial Enrollment Period: 3 months before and after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Switch, join, or drop an MA plan.
• General Enrollment (Jan 1–Mar 31): For those newly enrolled in Part B.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Change or drop your existing MA plan.
• Special Enrollment Periods: Triggered by:
  • Moving
  • Losing employer/union coverage
  • Gaining Medicaid eligibility
  • Medicare plan termination
  • Qualifying conditions (e.g., for SNPs)

What If You Want to Change Your Medicare Advantage Plan?

Plan changes can be made during:

• Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

What Are Medicare Resources in the District of Columbia?

• D.C. SHIP Program: Offers free Medicare counseling.
• D.C. SMP Program: Educates beneficiaries on fraud prevention.
• D.C. Department of Insurance, Securities and Banking: Handles Medicare-related complaints.
• District of Columbia Medicaid Program: Assists low-income residents. Call (202) 442-5988 or visit https://dhcf.dc.gov. Learn about the differences between Medicare and Medicaid.

Understanding Medicare Advantage Star Ratings

The CMS star ratings system is how the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) plans using a 5-star quality scale. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

CMS Star Ratings Overview

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

Other Medicare Plan Options to Help with Out-of-Pocket Costs

Medicare Supplement Plans (Medigap) help cover deductibles, copayments, and coinsurance left over by Original Medicare. Key features:

• Available only to those enrolled in Medicare Parts A and B.
• The ideal enrollment window is the six-month Medigap Open Enrollment Period.
• Medigap doesn’t include drug coverage; you must enroll in a separate Part D plan.
• Plans G and N are the most popular. Medicare Supplement Plan G had the highest 2023 enrollment.
• Plan F is no longer available to new enrollees post-2020.
• All Medigap plans provide predictable costs, nationwide provider access, and no referral requirements.

Learn more about Medicare Supplement plans in D.C.

Next Steps

If a Medicare Advantage plan in the District of Columbia fits your needs, compare available plans using the Medicare Plan Finder. Review network providers, prescription drug coverage, monthly costs, and extra benefits. Be ready to enroll when your eligibility period begins.